Treatment exceeded recommendations in majority of cases

Action Points

More than half of women with early-stage breast cancer treated with lumpectomy received more radiation therapy than they actually needed.

Note that hat the cost of radiation therapy for the overall cohort could have been reduced by 39% had patients received the least expensive strategy for which they were safely eligible.

More than half of women with early-stage breast cancer treated with lumpectomy received more radiation therapy than they actually needed, according to an analysis of the National Cancer Database.

Out of a cohort of 43,247 patients with T1-T2 NO invasive breast cancers treated with lumpectomy, 57% received longer -- and more costly -- radiation regimens than they could have received safely.

By use of an evidence-based approach, the study showed that the cost of radiation therapy for the overall cohort could have been reduced by 39% had patients received the least expensive strategy for which they were safely eligible, investigators reported online in the Journal of Oncology Practice.

"This study is an important reminder that there are treatment strategies that can retain high-quality cancer care, while reducing healthcare costs," lead author Rachel A. Greenup, MD, director of the Breast Fellowship at Duke University School of Medicine, said in a statement. "There are opportunities in cancer care to align high value care, patient preferences, and societal benefits of reduced healthcare spending."

The cost of treating breast cancer exceeds the cost for any other cancer, and the cost of radiation therapy is directly related to the number of fractions delivered: the longer the regimen, the higher the cost, Greenup and co-authors noted.

In an effort to reduce unnecessary treatment, the American Society for Radiation Oncology now recommends that women age 50 and over with early-stage breast cancer receive a shorter course of radiation therapy whenever appropriate. The healthcare system could reap important cost savings if evidence-based strategies -- involving hypofractionation or omission of radiation therapy altogether -- were routinely applied to patients following lumpectomy, the team noted.

For their analysis the authors compared conventional fractionated, whole-breast irradiation (CF-WBI), delivered over 5 to 6 weeks; a hypofractionated (3 to 4 weeks) course of whole-breast irradiation (HF-WBI); and lumpectomy without radiation therapy. Using the Medicare fee schedule, the researchers compared the cost of the radiation therapy actually received with the cost associated with evidence-based treatment.

The analysis involved women 50 and over treated for early breast cancer during 2011. On the basis of the defined criteria, 62.2% of the patients were eligible for hypofractionated radiation therapy, and 22.3% met the criteria for omitting radiation therapy altogether.

The results showed that 64% of the women received CF-WBI, 13% received hypofractionated radiation, 1% received accelerated partial-breast irradiation (APBI), and 22% received no radiation therapy. Of the 26,911 patients (62.2%) who could have received hypofractionated radiation, 13.1% actually received hypofractionated treatment, 68.4% received HF-WBI, 1% received APBI, and 22% received no radiation. The data showed that 15% of patients received less radiation therapy than recommended by the defined criteria.

Overall, 28% of the patients were treated with the least expensive radiation regimen for which they were potentially eligible. The cost of treating patients with the CF-WBI strategy averaged $13,358.37 per patient, compared with $8,327.98 for HF-WBI. The total cost of radiation therapy for the entire cohort was an estimated $420.2 million

"When costs were calculated, had women received the least expensive radiation therapy regimens for which they were safely eligible, treatment of the same cohort was estimated at $256.2 million," Greenup and co-authors stated. "This translated to an annual cost savings of $164.0 million."

By using Medicare costs for the study, the economic implications of the findings may actually be underestimated, as Medicare payments are usually lower than those of private insurers, the researchers added.

They noted that limitations of the study included the fact that the National Cancer Database may not fully capture the experiences of patients who elect to receive radiation therapy in a different setting from where they received their surgery. In addition, decisions reached by patients and their physicians are often not based on factors that can be adequately captured in a large database.

Don Dizon, MD, director of the Oncology Sexual Health Clinic of Massachusetts General Hospital in Boston and an American Society of Clinical Oncology expert, commented that many factors go into determining what constitutes high-quality, high-value care for patients, including clinical benefits and costs.

"This study suggests that the tailored use of radiation therapy -- including when not to use it -- based on clinical evidence, represents high-quality cancer care, particularly in women 50 years and older who undergo lumpectomy," said Dizon, who was not involved with the study. "At the same time, it also demonstrates that this evidence-based approach to treatment ... reduces the associated costs and further emphasizes the importance of the shared decision-making process between physicians and patients."

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